Medi-Cal HCBS: Why Medi-Cal is Critical for Older Adults

Yasmin Peled: Good morning, everybody. Welcome to today’s webinar, Medi-Cal HCBS, Why Medi-Cal is Critical for Older Adults. My name is Yasmin Peled, I’m the Director of California Government Affairs here at Justice in Aging, and I’ll be moderating today’s webinar. My colleague, Hagar Dickman, Director of California LTSS Advocacy will be presenting today’s webinar. Next slide, please. Some logistics before we get started. Everybody is on mute. If you would have any questions, please use the Q&A function for substantive questions, and also any technical concerns. If you’re having any problems getting onto the webinar, you can email trainings@justiceinaging.org, and you can find any materials from this training and past trainings from Justice in Aging at our Resource Library on our website. There will also be a recording of this webinar, and the slides of the presentation will be available on our website after the presentation, and they’ll also get emailed out to you.

If you would like to use closed captioning, please select the CC button on the bottom of the Zoom control panel. We have ASL interpretation today on this webinar. The ASL interpreter will stay on video throughout the training to provide this service. You do have the option to pin the interpreter’s video box to maximize your view of the interpreter. To do so, please click on their window and then select the pin icon. Next slide, please. So Justice in Aging is a national organization and we use the power of law to fight senior poverty by securing access to affordable healthcare, economic security, and the courts for older adults with limited resources. We’ve been doing this since 1972, and our focus is primarily on fighting for older adults who have been marginalized and excluded from justice, such as women, people of color, LGBTQ+ individuals, and people with limited English proficiency. Next slide.

Justice in Aging has a commitment to advancing equity, and we believe that we must advance equity for low-income older adults in their economic security, healthcare, housing, and elder justice. We address the enduring harms and inequities caused by systemic racism and other forms of discrimination that uniquely impact low-income older adults in marginalized communities. We also recruit, support, and retain a diverse staff and board including race, ethnicity, gender, gender identity and presentation, sexual orientation, disability, age, and economic class. I am going to turn it over to Hagar to get us started on today’s presentation.

Hagar Dickman: Thanks, Yasmin. So today, we’re going to be really focusing on California’s Medi-Cal covered home and community-based services. We’ll talk about who uses them and why they’re important for California’s older adults and people with disabilities, and then we’ll review some federal legislative proposals to cut Medicaid and talk about how those plans will impact California’s older adults and people with disabilities. And finally, we’ll review some tips for advocates and some messaging tips as well. And we have also made a variety of resources available on this webinar that you can download later on the slides and click to so you can review those later as well, and we will leave some time for questions. So we will review now Medi-Cal Home and Community-Based Services. And California has more than 2 million older adults and people with disabilities who use Medi-Cal. We receive $112 billion in federal funding to support our Medicaid program. And our Medicaid program in California covers a very broad set of services that are beyond the traditional medical… Medicaid services. Those include home and community-based services, nursing facilities, emergency transport, and financial assistance for Medicare beneficiaries who are dually-eligible enrolled for Medi-Cal.

And Medi-Cal also covers services that are not covered by Medicaid, those include dental, and vision, and hearing, and as we’ll talk about in a moment, long-term services and supports. There are about 1.5 million dually-eligible individuals who rely on Medi-Cal to cover their Medicare premiums and out-of-pocket costs. Dually-eligible individuals are very low income folks who have higher needs, and many of them participate in the Medicare savings programs, which makes Medicare more affordable. So for example, Medi-Cal will cover Part B premiums, which is currently at $185 per month. Medi-Cal is often older adults’ only option for long-term care, particularly because Medicare does not cover long-term care. Two thirds of California’s nursing facility residents use Medi-Cal to cover their nursing facility costs, and home and community-based services, particularly through waivers, help older adults who need nursing care to remain in their homes and be supported and have their needs met. And finally, for people whose income is above the pretty low Medi-Cal income limit, the share of cost program can provide access to care particularly for people in long-term facilities.

California has taken many steps over the last few years to expand Medi-Cal and make sure that our highest needs populations are able to access the program, both by increasing our income limit to 138% of the federal poverty level, which is now the highest income limit for Medicaid for the aged and disabled category, eliminating the asset test for Medicaid, so you no longer have to show that you have low assets in order to participate in Medi-Cal, and then extending coverage to individuals who are undocumented. That process was completed in 2024 with the inclusion of individuals under 65. So turning our attention to long-term services and supports and really thinking about how those services are delivered in Medi-Cal. Federally, federal regulations require all states to include nursing facility, and institutional care, and home health in their state Medicaid plan, but the federal regulations also allow for some optional services that the state can choose to offer Medicaid participants. So all of the home and community-based services, for example, that California has, those are all optional benefits that California has decided to include in its Medicaid plan, Medicaid services.

Home and community-based services are services that support older adults who have functional impairments and require assistance with activities of daily living, and these are services that often help people with functional impairments to stay in their communities and in their homes with additional support. Medi-Cal is the main payer of HCBS services, or home and community-based services. People who are not eligible for Medi-Cal will have to either pay out of pocket or obtain a long-term care insurance, and only 8% of Californians have long-term care insurance. So most people either rely on Medi-Cal for home and community-based services, pay out of pocket, or have to go without. Again, like we talked about, these are optional services that California has decided to include as a Medi-Cal benefit. California uses different federal authorities to offer home and community-based services. The first is through state plan. So anything that’s in the state Medi-Cal plan is a benefit that has to be provided statewide without limiting by population to anyone who’s eligible and is in Medi-Cal.

So the state can’t have wait lists for a state plan benefit, and it can’t limit by population. The state can offer also a home and community-based state plan option. Those can be targeted for specific populations, but again, can’t have wait lists, and have to be offered statewide. And finally, we can use Medicaid waivers, and these waivers allow California to limit access to specific areas in the state, or for example, limit by counties. We can also use waivers and focus on specific populations or special eligibility groups, for example, age or disability type. And we can also use waivers to limit access by using cap limits. And so these waivers have often carried long wait lists.

These are California State Plan amendment, state plan services, nursing facility, and home health. These are our mandatory services that have to be provided statewide. We have a 1915(i) HCBS plan benefit for individuals with intellectual and developmental disabilities. Again, these are services that are provided statewide but with a population of focus. And then our in-home support services program is a state plan program, so it is available statewide and has no wait lists, and it’s also available for individuals with high level of need through the 1915(k), or Community First Choice option program. This is IHSS pathway for individuals who need nursing facility services but choose to receive those services in their home.

We also have a variety of waivers. Our community-based adult services program or Adult Day Health is available through managed care services. And then we have waiver programs that often have wait lists, these are the Assisted Living, Home and Community-based Alternatives, Multi-Senior Services Program, and Medi-Cal waiver for I/DD. And these are available for individuals with high level of need. So in order to get these services, people have to require nursing facility care, but are choosing to participate in these programs instead and receive these nursing type services at home. And then we’re going to talk about the new CalAIM Community Supports and Enhanced Case Management programs, which are HCBS-like programs and they’re offered through Medi-Cal managed care participants. And then finally, we have Program of All-inclusive Care for the Elderly, or PACE, which is offered as a managed care type plan that includes comprehensive, both medical and nonmedical, services. And people who participate in the PACE program have to receive all of their care through PACE participating providers, including HCBS services.

This slide here is really a landscape slide to show who is using the program and how many people are in each program. You can see here that Medi-Cal is responsible… So Medi-Cal is responsible for providing people with services and supports in all kinds of settings. The most important and fundamental of those supports are personal care services, which are the type of care services that people often need to stay at home, cleaning, toileting, feeding, dressing, grocery shopping, and sometimes supervision. And Medi-Cal delivers these services through all of these different programs. You can see here that the IHSS program is the biggest program by far. It accounts for almost all of our personal care services, totaling over 800,000 people who are participating. Unlike other programs, as I mentioned before, IHSS is available in all counties for anyone who is eligible and has no wait lists. And then other home and community-based programs are limited in capacity and geographic availability and carry long wait lists.

And the reason this slide is here is to really drive home the point of how many people in California really depend on these services for staying in their community. And when you look at those wait lists, that’s really an indication of how necessary these programs are. The Assisted Living Waiver Program, for example, has 7,700 people on the wait list right now, just to highlight how many older adults and people with disabilities are really needing this program right now and depend on it. So of the 800,000 people receiving IHSS, nearly 55% of them are older adults. And the reason I mentioned that, and as you can see actually in the previous slide, a lot of these programs are really necessary, especially for older adults who are wanting to remain in their community and out of nursing facility care. And IHSS is available for people needing nursing facility care or at risk of needing nursing home care. And then 87% of waiver participants are older adults as well, and those are really specifically focused on replacing nursing facility care with home care.

And then I wanted to just highlight that a lot of… there was a recent study by UC Labor Center that talks about how IHSS caregivers and other home caregivers are really relying on Medi-Cal as well for their caregiving. So any cut or impact to Medi-Cal is going to really impact caregivers as well as Medi-Cal recipients. I’m going to review CalAIM benefits right now and then we’ll proceed to advocacy tips. So CalAIM is a new initiative that California has been pursuing to really change the delivery of Medi-Cal services to be administered by managed care plans. And through the CalAIM program, the state has created two new services, one is Enhanced Care Management and the other is Community Supports, and these are really home and community-based like type services. They’re administered by the Medi-Cal managed care plans, but the plans contract with third party community-based organizations who actually deliver the care and the services.

Enhanced Care Management is a intensive case management service, and it’s really led by a lead care manager who knows every component of the member’s needs and services to ensure that they’re coordinated, and that individual will coordinate both clinical and non-clinical needs and services, including services outside of the managed care system. And this program is limited to people who fit the eligibility requirements under the population of focus. There are six population of focus groups. So for the first one, if you or your family are homeless or don’t have a stable place to live or at risk of homelessness, maybe you’re staying on a friend’s couch, then you would be able to access the ECM service.

If you’ve had five or more emergency visits, or three or more unplanned hospital visits, or short-term skilled nursing facility stay in the last six months, you can also qualify for ECM as an adult at the risk of hospital or emergency department utilization. If you have a serious mental health condition or struggle with drug or alcohol use, or if you’re transitioning from incarceration, or at risk of entering a nursing home or facility, or staying in a facility and want to transition back to the community, all of these would have qualified you for ECM services. The managed care plans are supposed to identify people who might be eligible as a population of focus, but also community support… sorry, community providers and family members, as well as Medi-Cal members themselves can refer to ECM services.

Community Supports are… these are services that are mimicking a lot of the home and community-based services out there, and they’re really designed to address social determinants of health related to housing, to healthcare, housing insecurity, and food insecurity, and economic insecurity. Some of these services have lifetime maximums or restrictions, and all of the details about what the eligibility criteria for each service and what the limitations are are written in their Community Supports definition guide, and there’s a link to that guide at the end of this presentation. These are all supposed to be medically appropriate and cost-effective services or settings that are offered by the managed care plan as a substitute for state plan-covered services or settings.

These are the 14 Community Supports that can be offered. These are all optional at this point for the managed care plan, so they do not have to actually provide these, each managed care plan decides which of these they want to offer. And so when advocating for a consumer and helping identify which services they can get, it’s really important to first figure out what plan they’re enrolled in, and then going onto that plan’s website and seeing which Community Supports are offered through that plan. Just a quick focus on housing here, the housing Community Supports are the transition navigation services and the deposit services. These help with finding housing, negotiating with a landlord, paying first month’s utilities, and education on how to be a tenant. Housing deposits can really help people with their security deposits, and then housing tenancy is there to help people with the housing itself.

So to be eligible for Community Supports, you do not have to be a population of focus. Each community support has its different individual criteria, and also, like I said before, its own limitations. And some Community Supports you can receive together, so they don’t necessarily duplicate each other. So as long as they’re not duplicative of one another, you can actually receive multiple Community Supports at the same time, and you can receive ECM and Community Supports at the same time as well. And then many Community Supports are similar to Medi-Cal covered home and community-based services. So in that case, you have to actually be careful not to duplicate services, you have to sometimes choose one or the other.

You can receive the Community Supports through self-referral or through referral from an ECM or a contracted community support provider, and you can also receive a referral from a managed care plan. So these Community Supports have really been significantly underutilized. For example, the diversion or transition to assisted living community support really mirrors the assisted living waiver, which has 7,700 people on its wait list. That community support can really be used to clear the wait list but only has around 750 people who used the service in the last 12 months of reporting. So if you are on the wait list for assisted living waiver, or you know someone who is, you may be able to access the assisted living services through this community support. You’ll need to determine whether your plan has the service and then refer the individual through the self-referral process, or if you’re a contracted community support provider, you can also make the referral by going through the plan’s provider referral process as well.

So I’m going to review now some threats to Medicaid that are coming down from the federal government, and we’ll talk also about how these threats are impacting… are a threat to the services that we just talked about and the people who are receiving these services. So the first federal proposed policy is a block grant. As I mentioned before, California is receiving $112 billion in federal matching for its Medicaid program. So if the federal government decides to use a block grant method, they can decide that instead of paying or covering a percentage of our Medicaid spending, they could just limit that spending and say, “Federal government’s going to give just this chunk of money to California,” and then after that, there’s no more money available regardless of how much the state is spending on services or how many people we are covering. What that could do is really limit the amount that California can depend on for reimbursement from the federal government, and at that point, we will need to either pay for that spending from the general funds or cut back on services.

The second method here is per capita caps, and those caps are really based on individual utilization. So those are limits on how a person can actually… how much services a person can actually use for Medicaid. A per capita cap can really impact people who need home and community-based services or long-term care because those are the most expensive Medicaid services. And so a person, for example, who goes into long-term care or receives a home and community-based service can reach the cap a lot faster and no longer be able to access Medicaid services after reaching that cap. Cutting the Federal Medical Assistance Percentage, or the FMAP, is also a way of limiting how much the feds are going to be sharing or reimbursing California for Medicaid spending.

Right now, California is receiving 50% federal matching, so the federal government pays for… or reimburses 50% of all Medicaid spending for the state. If there was a cut to that rate, for example, if the federal government decides to go down to 40%, California will either have to make up the difference, or we’ll have to, again, cut services so that we can afford that lower level of participation. The third proposal is to restrict provider taxes. Because the Medi-Cal program first requires California to pay for services and then to request a reimbursement from the federal government, the state has been using provider taxes to fund that initial payment. If there’s a restriction on those provider taxes, California is going to see a reduction in that stream of income for the state, and we’ll be able to afford less services to be covered upfront before receiving reimbursement from the feds.

And that’s going to impact the state long-term, that if we provide less services, we’ll then be able to only get less reimbursement from the feds, and that will impact our ability in the long-term to provide services again. The federal government is also looking to restrict who can participate and also how services are delivered and what kind of services are delivered. One of those methods of pursuing Medi-Cal cuts is putting place work requirements. Work requirements are often talked about in terms of preventing waste or fraud, but actually, what they do is put in place additional administrative burdens that make it really difficult for people to access services and to get on to Medicaid. And if you think about the reason that California got rid of its assets test, it’s really to eliminate administrative burdens that get in the way of people getting Medi-Cal. And so putting in place work requirements is really a step backwards, it’s going to make it difficult for people to enroll, and is really going to be a cut to Medicaid in who can access our services.

One of the other things… We just talked about CalAIM, and one of the other things that the feds are looking at doing is really preventing the state from providing those additional services that go towards the housing, and things like that, that really help go towards social determinants of health. And so one of our concerns is that a cut to those services will prevent California Medi-Cal system from providing services that really help our high needs populations. So it’s really important to remember that all of these reforms are cuts to Medi-Cal. We don’t need to really wait to know what the policies are moving forward in legislation to fight back or to fight against them, and that’s because all of these reforms are cuts to Medicaid and all of them would harm older adults. One in five people on Medicare rely on Medicaid to afford health and long-term care, so Medicaid would really arm people with Medicare as well. We’ve already seen the impact of home and community-based services users on budget shortfalls in previous economic downturns.

We could just remember from 2013 when California cut IHSS by reducing hours when it had a budget shortfall, it eliminated adult dental services and it tried to eliminate CBAS and the MSSP programs when they thought there was a budget shortfall during COVID. And then last year, when California had a budget shortfall, undocumented people were at risk of losing access to IHSS. So this is a good reminder that if we’re going to see Medicaid cuts, it’s reasonable to expect that our home and community-based services, particularly because they are both optional services and expensive ones, that they’re going to be on the chopping blocks, and we should take steps now to really fight these cuts in order to make sure that we don’t see impact on these services. Also, because dental, vision, and hearing services are optional, we can also expect those to be at risk.

And then we talked before about how California has taken steps to expand Medicaid eligibility, we’ve expanded our Medicare savings programs, and we’ve eliminated our asset tests. And so those are at risk as well, because if California is going to need to limit access to Medi-Cal in order to limit spending, any Medi-Cal expansion is at risk of being rolled back. And then finally, cutting provider payment rates is a different way that the state can also reduce spending on Medicaid, and that will, we expect, really worsen the direct care workforce shortage that we’ve been seeing exacerbated during COVID… in the post-COVID years. So we’ll talk a little bit about what you can do to fight these cuts. And a lot of what we are asking our network to do is to really oppose any Medicaid cuts now and communicate with congressional offices as often as you are able.

We hear from staff in congressional offices about the importance of hearing from constituents, both you and your clients, or your community. And so feel free to use Justice in Aging’s resources. We have letters and other templates that you can use that can really help inform your communication with your congressional representatives. And also speaking to your state officials is really important, especially we want people in the state level to hear how important these services are to older adults and to people with disabilities. And so making sure that that gets communicated is really important as well. We’re currently focusing on Districts 22, 40, and 41 at the congressional level, because these districts in California have the highest population of Medi-Cal enrollees and are also represented by Republicans. And because we only need to change the minds of a few Republicans, we think focusing on these districts is going to be helpful.

We also think that educating is really important. We know a lot of members of Congress and their staff don’t really know or understand the role or importance of Medicaid for older adults. Even if you can’t lobby, helping with education is really important. Uplifting the importance of Medicaid for people with Medicare in their states… in California, within the context of work that you’re already doing and then making sure that your clients understand that they’re actually enrolled in Medi-Cal. For example, we sometimes hear that people don’t realize that IHSS is a Medi-Cal program. So making sure that Medi-Cal service recipients know that those services are Medi-Cal services, and that they should be also expressing why Medi-Cal is important to them, and why those services are important to them is going to be important. And then sharing those stories directly with members of Congress or with us is very helpful. And we are also collecting stories, especially from those districts that I had mentioned. So if you have any stories about the importance of Medi-Cal services to your constituency, please feel free to reach out.

So there’s two overarching points here. So there’s a misconception that the proposals that we just talked about won’t hurt older adults, but like we just talked about, they will. Any of these cuts is going to hurt older adults and people with disabilities, and there’s really no way to shield any specific population from feeling the pain of these cuts. And focusing on older adults we find is a message that resonates with policymakers. So even if your focus population is not older adults, there’s an opportunity here to make clear that any cut hurts not only your focus population, but also older adults and people with disabilities.

Finally, don’t assume that people know what Medi-Cal is or how it helps older adults. So really talking about all of these services and educating people about why these services are important for keeping and supporting people who want to live in the community is important. And then always referring to the proposed reforms as cuts is important, because I think the people who are proposing these cuts are trying to sell them as some sort of reform. These are not reforms, these are cuts to the Medicaid program. And then making clear, again, that seniors are going to be hurt. Focus on the impact rather than the details. Who’s going to be hurt? It’s going to make affordability more difficult, it’s going to increase unmet needs, and it’s going to impact quality of life and health outcomes.

So these are some top line messages that we encourage you to use in your communication. And feel free to use them when you call or when you write to your congresspeople as well. There are some resources here that you are welcome to use, these are all linked on the PowerPoint that you will get after the presentation. The sign-on letter at the end here is a letter that we had sent with partners. Feel free to take that letter and adapt it to your own needs, and use whatever material you find relatable to your situation or point of view. And here are some additional resources. If you’d like to get involved, you can join Justice in Aging’s alerts. You can also join the Protect Medicaid Listserv and the Fight4OurHealth Coalition. I’m going to take some questions now. Yasmin, do we have questions? I can’t see them from my end right here.

Yasmin Peled: If you could repeat the districts for people where we’re focusing on story collection, please?

Hagar Dickman: Sure. We’re focusing on congressional district 22, 40, and 41.

Yasmin Peled: There’s one question here about CalAIM and ECM. The question is, “Why does it have to be under managed care? Some of my Medi-Cal clients do not have encumbered Medi-Cal.”

Hagar Dickman: That’s a really good question. So ECM specifically is a CalAIM service that’s available through the CalAIM program. CalAIM is only available for people who do not have a share of cost that accounts for most, but not all, of Medi-Cal users. And it also is not available for people who are in a dual… in a D-SNP, a dual special needs programs, a plan, because those plans have their own care management program. So in order to be eligible for ECM, you first of all have to be enrolled in the CalAIM Managed Care program because that’s how the service is written, it’s just a service specifically for people who are participating in managed care.

Yasmin Peled: Another question here about the potential Medicaid cuts, “What is the timeframe of cuts that we need to prepare for?”

Hagar Dickman: That’s a really good question. It’s a little bit hard to tell… to say. So last week, a budget resolution was passed in the House of Representatives, and now, the House of Representatives and the Senate have to agree on a budget resolution to go forward and proceed. So we already know that the House of Representatives had agreed to an $880 billion cut to spending, and there is no way to pay for that spending without Medicaid cuts. Because the next step is this reconciliation with the Senate, this is an excellent time to contact your members of Congress and continue putting pressure to not enter into a agreement with the Senate about these cuts and to resist any sort of Medicaid cuts right now.

Even if this fails, there’s probably going to be future attempts. So it’s important to stay engaged and involved in resisting or opposing Medicaid cuts. But I think, right now, within the next couple of months, is a really excellent time to start fighting against them, just because, right now, this is what the conversation is in Congress. I can’t tell you when it’s actually going to happen, so I’m going to just say communicate now and do it often.

Yasmin Peled: There’s a question here, “Is IHSS at much risk as WPCS?”

Hagar Dickman: Well, I think WPCS is a… that’s a waiver… that’s through the HCBA program. It’s very similar to IHSS, but provided through the waiver. I think the way that WPCS would be impacted is if the state needs to roll back or no longer deliver the HCBA waiver. But the number of people in HCBA is much lower. So we have 800,000 people in IHSS. So I think any impact on IHSS, you’re going to feel with HCBA, with the WPCS hours being reduced. So for example, if you see a reduction in IHSS hours, you’re probably going to see those in WPCS hours as well. But as far as which one is going to go first, I don’t know. I think it’s worth saying that we should make sure that no programs get touched because they’re going to impact populations in one way or another.

Yasmin Peled: We’re getting additional questions about the districts that are the focus, so maybe I’ll just-

Hagar Dickman: Yeah, do you want to put them in the chat?

Yasmin Peled: I can put them in the chat, but I’ll just say that it’s California District 22, which is represented by David Valadao, and he represents parts of the Central Valley, including parts of Kern County, Tulare County, and Kings County. The other area is California District 40, which was represented by Young Kim. She is in Orange County and represents areas of Anaheim, Santa Ana, Mission Viejo. And then lastly is California District 41, represented by Representative Ken Calvert. This is in Riverside County, and he represents areas of Corona, Lake Elsinore, and Palm Springs. And we can put that in the chat, so everybody has that information. And the reasoning for focusing on these representatives at the moment is that their districts have very high population of individuals on Medi-Cal. There’s a question here, “Do we think that ECM services could be affected by cuts?”

Hagar Dickman: Yes. I think it’s safe to say that any service is at risk of cuts, partially because if the state has a budget shortfall because of federal cuts, it’s going to force the state to make some very hard decisions, and one of those decisions is going to be which services are we going to continue paying for? Any service that we ask the managed care plans to deliver is going to increase the capitation rates that the state pays for the plans. And so those services are at risk. Another reason that services might be at risk is if the federal government provides guidance or instructions saying that the feds will no longer pay for specific services. There has been some talk of those services that really go to social determinants of health, including care management, is going to be at risk because the federal government feels like these are not traditional Medicaid services that should be included in the Medicaid plan. So I would say that those are a service that is at risk.

Yasmin Peled: Another question, “We have seen that CalAIM has had a positive impact in counties where it’s been implemented, how is this information being quantified?” So it’s a-

Hagar Dickman: Oh, you went on mute, Yasmin.

Yasmin Peled: So it’s about data collection and CalAIM.

Hagar Dickman: Yeah, I think you can go… So California… DHCS has a data dashboard that they use, it’s a implementation report that’s updated, I think, quarterly on the DHCS website, and you can look at utilization by plan, and by county, and by service. You can really see which plans are providing which service, and how many people are accessing that service. I think, right now, that’s the place to look for quantifying at least utilization. I think impact is too soon to tell. We would want to see over time what impact this has on homelessness, on nursing home stays, and things like that, but that’s going to take a couple of years, I think, to be sorted out. So I would wait and see. I did want to highlight that the state just published its HCBS gap analysis. And so I think looking at that gap analysis, there’s a lot of really great data there about really where we’re starting from. The dates that they looked at is 2017 to 2021, and I’m really looking forward to seeing what the impact is on those gaps over time as well.

Yasmin Peled: I have another question here about potential HCBS cuts, “And would these cuts force more people into nursing homes? Doesn’t the state pay more for nursing homes under Medi-Cal than for HCBS?”

Hagar Dickman: So I agree with… the preface of the question, which is if we are forced to cut access to HCBS, aren’t our costs going to go up, and don’t those costs translate to higher costs for the federal government? I think that under certain models, that’s true. So if we’re just receiving a lower federal matching, that will cause us to maybe reduce the number of people that we’re serving, it will definitely increase… I’m sure it’ll increase the number of people in nursing homes, and that will, probably in the long term, translate for higher costs for both the feds and for California. But if California is seeing a block grant, which limits the total spending, then even if people end up in nursing home care, those people are not going to be on the… there’s not going to be federal matching for those folks for Medi-Cal. And so that’s going to have an economic impact, and maybe nursing home support is going to be less available as well.

So I think no matter how you look at this, there’s going to be financial impact for the state and decreased services, and you’re going to see less people being able to access both HCBS and nursing home care.

Yasmin Peled: “If your district wasn’t mentioned, how can we get involved?”

Hagar Dickman: We highly recommend that even if your district is not in the districts we mentioned, that you contact your own congressional district. I contacted my Democratic congressional representative three times in the last three weeks and had all my family members do the same, because it’s really important that not only the Republicans flip their votes on this, but also, the Democrats are emboldened to fight this as hard as they can. So part of making sure that we have allies and people who are standing up for us in Congress is also making sure that they hear from constituents and democratic districts. We want to make sure that our Democratic representatives are emboldened and really know how important Medi-Cal is for us in California and how unified we are in fighting Medi-Cal cuts because they impact every Californian. There’s one more thing, which is that we are hoping that even if you’re not in an impacted district, that if you know someone in an impacted district, organizations, or IHSS, or other consumers in these districts, that you contact them and try to connect them with us as well, that’s another opportunity.

Yasmin Peled: We answered this question earlier, but just once again, “Will cuts potentially affect CalAIM and ECM and Community Supports?”

Hagar Dickman: Yes. So we anticipate cuts to impact the delivery of all services. So there is potential to cut… If the state has to make difficult choices about where to do those cuts, they can cut services, and those include the services that are offered under CalAIM. Community Supports and ECM are all optional services for the state, they are included in the state capitation rates that are paid for the managed care plans and eliminating those will bring savings and reduce costs. The other place that the state can see costs is by just reducing the number of people who are able to access Medicaid in general and the people who are accessing CalAIM as well. So those are kind of two ways in which CalAIM can be impacted, either by the reduction of services or the number of people who are able to access a service.

Yasmin Peled: A different question about CalAIM. Someone writes here that she helps seniors apply for CalAIM, but that every county does things differently. Is there any way to streamline this or is there a way to get more information about how to help people with when everything is so different?

Hagar Dickman: I think that is an excellent question. And one that we have been advocating for with Department of Healthcare Services, and I highly recommend you do the same, communicating with the Department of Healthcare Services to talk about the difficulties that you are experiencing in enrolling people and what the impact is of having non-standardized referral and enrollment processes is really important. So what we’ve been asking for is a standardized enrollment and referral process for Community Supports, as well as making all Community Supports mandatory for each plan so that we don’t have variation across plans and counties. That’s the best I’ve got for you. But I think it’s definitely… it would be great to have partners in this advocacy and really uplifting the difficulty of non-standardized services and referral processes across plans.

Yasmin Peled: There’s another question here… Sorry, my mouse stopped working. “Can you speak a little bit more about 1915(i) services for I/DD populations?”

Hagar Dickman: I can’t speak in detail because it’s not… my focus is older adults, I don’t know a lot about the… I believe the services are mostly habilitation services that are included in 1915(i), but in general, a 1915(i) HCBS state plan benefit is a HCBS benefit that does not have a cap, so there’s no wait lists, and it requires a state to provide the service statewide to anyone who meets the eligibility criteria. But unlike a state plan benefit, a 1915(i) benefit can be focused on a specific population. So that’s the reason that that particular service is available only for individuals who are in the I/DD population, is because the state has decided to focus it on targeted population instead of a more expansive service. There are more differences there, but I don’t want to give a whole hour lecture on 1915(i). So we could talk about that… I can answer those questions separately if you have specific questions about 1915(i).

Yasmin Peled: Another question here, “Can we assume that folks with Medi-Cal with share of cost are at high risk of losing IHSS, HCBS, Medi-Cal?”

Hagar Dickman: That’s it… Well, I think the way that one, in the share of cost category, would lose access is most likely through unaffordability. So already, people in share of cost Medi-Cal have a very difficult time accessing services because their share of cost requires people to live on $600 a month and spend the rest on medical expenses. I can see making that program more difficult to access by making the share of cost even higher. So if we reduce the maintenance need level from 600 to a lower level, it could reduce it to $300. I think New Jersey is about three or $400 a month, then that would make it more difficult for individuals to meet their share of costs and access those services.

Yasmin Peled: “Will there be any impact on exclusively aligned enrollment, or D-SNPs, based on some of the cuts that are being discussed?”

Hagar Dickman: I’m not sure if there’s a specific targeted plan to impact those plans. Actually, I’m not able to answer that. So I can respond later in writing. I’m happy to look into it and see if there’s anything specific around D-SNPs.

Yasmin Peled: “To reduce costs in Medi-Cal, could the state consider dropping paying for premium payments for those in Medicare?”

Hagar Dickman: Yes. Yes, the state could choose to do that, they could also choose to reduce… One of the ways to do that is to actually reduce the income limit for Medi-Cal eligibility so that you could only benefit from premium reimbursement or coverage if you are lower income. So we’ve already done that before, our income limit used to be 122%, so people at 138% FPL income level didn’t benefit from their premium coverage. So that’s a way of limiting access to that benefit.

Yasmin Peled: I think we’ve already answered this, but maybe just to reiterate, any potential timeline on when cuts could go into effect?

Hagar Dickman: Yeah. So I think what I had said before is that it really depends on how quickly the federal government ends up… how quickly the Senate and the House agree on the budget resolution through reconciliation and other procedures. So because the Congress had… sorry, the House of Representatives passed a budget resolution last week, and the Senate also passed a budget resolution, they now are in the negotiating phase. And so this is a really good time to oppose, but there’s nothing particularly final right now. But again, this is a very important time and really crucial time to advocate and to call and communicate with your congressional people because they really need to hear that you do not want to see the outcome of this reconciliation with a budget cut to Medicaid.

The other thing, again, I’ll repeat is that even if we succeed this time, this is something that the feds can repeat and continue to work on and try to accomplish over the next two to four years. So this is going to be a marathon, and it’s going to be important that we all continue to communicate with our representatives, and continue educating and advocating on this issue. So it’s not only a now issue, it’s going to be a next four years issue.

Yasmin Peled: “Could California reinstate resource caps like the asset test?”

Hagar Dickman: California could reinstate the asset test. Again, the asset test has gone… the way that the asset test has really limited people in accessing Medi-Cal is by providing an additional administrative barrier. It’s not that we are seeing a lot of high-resourced individuals on Medi-Cal all of a sudden, it’s more that the paperwork and the steps required to show that people meet the low asset limit has really prevented people from getting onto Medi-Cal. So I don’t anticipate the state looking at that one first, only because I don’t think that that would be bringing a lot of savings for the state. It’s not going to make a lot of people ineligible, it’s only going to make it difficult to get onto Medi-Cal. I think it’s more likely that the state is going to pursue either service cuts or across the board reduction in access through things like lowering the income limit.

Yasmin Peled: Then maybe one of our final questions, “In the case of potential cuts, do we need to be lobbying our local legislators with our concerns for specific programs?”

Hagar Dickman: I think the more representatives that are aware of constituent needs and constituent demands, the better. So yes, I think lobbying local leadership is going to be important. I don’t think necessarily local leadership is going to be the one that’s going to be deciding what happens with the Medicaid cuts, but it’s good to be as organized as possible, and the more people that understand what the needs are, I think the better. So yeah, I would agree with that. I think if you’re thinking about actual local funding streams, we’re going to have local populations that are going to need housing supports, and they’re going to need healthcare supports, and so making sure that, again, educating your local representatives is going to go a long way, and making sure that they’re aware of population needs and when they need to step in.

Yasmin Peled: Okay. I think that we will… some of the more specific questions Hagar will answer following the webinar, so I think that we will stop the Q&A at this point. Hagar, do you have any final comments you’d like to leave our participants?

Hagar Dickman: No, just feel free to reach out with any questions. My email is here on the slides, and I’m happy to communicate about any questions or any advocacy tips or details about California’s HCBS that you have. Thank you so much for joining.